Cavernoma portal complicada con biliopatía secundario a enfermedad de Gaucher tipo 1: reporte de un caso peruano / Cavernoma complicated with biliopatia secondary to type 1 Gaucher disease: report of a Peruvian case

La enfermedad de Gaucher, es un trastorno autosómico recesivo de depósito lisosomal que se caracteriza por deficiencia de la beta-glucocerebrosidasa que lleva a la acumulación de glucosilceramida principalmente en células del sistema fagocítico mononuclear causando afectaciones sistémicas. Se presenta paciente varón de 20 años que cursa con dolor crónico en hipocondrio izquierdo con episodios de sangrados desde hace 3 años y sensación de alza térmica, al examen físico se identificó ictericia y esplenomegalia masiva, sin afectación neurológica. Como apoyo al diagnóstico se mostró osteoporosis severa, pancitopenia y como hallazgo inesperado la presencia de trombosis de vena porta con transformación cavernomatosa complicada con biliopatía portal simulando un tumor de klatskin, los estudios de médula y enzimáticos eran compatibles con enfermedad de Gaucher, por lo cual recibió tratamiento con imiglucerasa realizando seguimiento. Es un caso poco frecuente, de gran interés, heterogeneidad en sus manifestaciones clínicas e inéditas por su complicación, constituyendo un desafío llegar a su diagnóstico de esta enfermedad huérfana.

Gaucher disease is an autosomal recessive lysosomal storage disorder characterized by deficiency of beta-glucosidase that would lead to the accumulation of glucosylceramide mainly in cells of the mononuclear phagocytic system causing systemic effectations. We present a patient of twenty years who is suffering from chronic pain in the left hypochondrium with episodes of bleeding for 3 years and sensation of thermal rise, physical examination revealed jaundice and massive splenomegaly, without neurological involvement. Severe osteoporosis, pancytopenia, and the presence of portal vein thrombosis with cavernomatous transformation complicated by portal biliopathy simulating a klatskin tumor, marrow and enzymatic studies were compatible with Gaucher disease, were shown as unexpected findings. he received treatment with imiglucerase, following up. It is a rare case, of great interest, heterogeneity in its clinical manifestations and unpublished by its complication, constituting a challenge to reach its diagnosis of this orphan disease.

Validez de la prueba de actividad enzimática de la glucocerebrosidasa para el diagnóstico de enfermedad de Gaucher, revisión sistemática / Validity of the Enzymatic Activity Test of Glucocerebrosidase for the Diagnosis of Gaucher Disease, a Systematic Review / Validade do teste de atividade enzimática da glucocerebrosidase para o diagnóstico da doença de Gaucher, revisão sistemática

Introducción: La enfermedad de Gaucher es un trastorno metabólico por deficiencia o ausencia de enzima ß-Glucosidasa Ácida. El diagnóstico se sospecha clínicamente, pero requiere confirmación mediante medición, en leucocitos (estándar de oro) o en sangre seca sobre papel de filtro, de la actividad de la enzima ß-Glucosidasa Ácida. Objetivo: Evaluar la validez de la medición de la actividad de la enzima ß-Glucosidasa Ácida en sangre seca en papel de filtro, comparada con el estándar de oro, para el diagnóstico de enfermedad de Gaucher en pacientes con sospecha clínica. Metodología: Se hizo una revisión sistemática de literatura. Se construyó y validó una pregunta PICO. Se usó una estrategia de búsqueda genérica con base en los términos clave (Gaucher Disease y Dried Blood Spot Analysis). Dos evaluadores independientes revisaron, evaluaron la calidad y extrajeron la información de los artículos. Resultados: Descartando los duplicados, se obtuvieron 47 artículos. Se evaluaron los textos completos de cuatro, y tres de ellos fueron excluidos al aplicar criterios de inclusión y exclusión. El artículo incluido tuvo una calidad excelente y mostró que la actividad enzimática de la glucocerebrosidasa en sangre seca tuvo sensibilidad de 82.3% y especificidad de 94.0% con un punto de corte de 0.0-2.75 y sensibilidad de 88.2% y especificidad de 88.5% con un punto de corte de 0.0-4.4. Conclusiones: La medición enzimática de la ß-Glucosidasa Ácida en sangre seca es una excelente prueba para diagnóstico inicial de enfermedad de Gaucher. Sin embargo, no es una prueba concluyente. [Vera-Cala LM, Serrano-Gómez SE, Córtes A, Estrada I, Gáfaro A. Validez de la prueba de actividad enzimática de la glucocerebrosidasa para el diagnóstico de enfermedad de Gaucher, revisión sistemática. MedUNAB 2017; 20(2): 201-206].

Introduction: The Gaucher disease is a metabolic disorder due to deficiency or absence of acid ß-glucosidase enzyme. The diagnosis is clinically suspected, but requires confirmation by measuring the activity of acid ß-glucosidase enzyme in leukocytes (gold standard) or in dried blood on filter paper. Objective: To assess the validity of the measurement of acid ß-glucosidase enzyme activity in dried blood on filter paper compared to the standard of gold, for the diagnosis of Gaucher disease in patients with clinical suspicion. Methodology: A systematic review of literature was carried out. A PICO question was constructed and validated. A generic search strategy was used based on the key terms (Gaucher Disease and Dried Blood Spot Analysis). Two independent evaluators reviewed and assessed the quality, and extracted information from the articles. Results: Discarding the duplicates, 47 articles were obtained. Four complete texts were evaluated, and three of them were excluded when applying inclusion and exclusion criteria. The article that was included had an excellent quality and showed that the enzymatic activity of glucocerebrosidase in dried blood had a sensitivity of 82.3%, a specificity of 94.0% with a cut-off of 0.0-2.75, a sensitivity of 88.2% and specificity of 88.5% with a cut-off point of 0.0-4.4. Conclusions: The enzymatic measurement of acid ß-glucosidase in dried blood is an excellent test for an initial diagnosis of Gaucher disease; however, it is not a conclusive proof. [Vera-Cala LM, Serrano-Gómez SE, Córtes A, Estrada I,Gáfaro A. Validity of the Enzymatic Activity Test of Glucocerebrosidase for the Diagnosis of Gaucher Disease, a Systematic Review. MedUNAB 2017; 20(2): 201-206].

Introdução: A doença de Gaucher é um transtorno metabólico devido a deficiência ou ausência de enzima de ß-Glucosidase. O diagnóstico é clinicamente suspeitado, mas requer confirmação medindo, em leucócitos (padrão-ouro) ou em sangue seco em papel de filtro, a atividade de enzima de ß-Glucosidase. Objetivo: Avaliar a validade da medida da atividade de enzima de ß-Glucosidase em sangue seco em papel de filtro, em comparação com o padrão-ouro, para o diagnóstico de doença de Gaucher em pacientes com suspeita clínica. Metodologia: Foi feita uma revisão sistemática da literatura. Uma questão PICO foi construída e validada. Uma estratégia de pesquisa genérica foi utilizada com base nos títulos-chave (Doença de Gaucher e Análise de Pontos de Sangue Seco). Avaliaram dois avaliadores independentes, avaliaram a qualidade e extraíram informações dos artigos. Resultados: Descartando as duplicatas, foram obtidos 47 artigos. Os textos completos de quatro foram avaliados e três deles foram excluídos ao aplicar critérios de inclusão e exclusão. O artigo incluído teve uma excelente qualidade e mostrou que a atividade enzimática da glucocerebrosidase em sangue seco teve sensibilidade de 82.3% e especificidade de 94.0% com um corte de 0.0-2.75 e sensibilidade de 88. 2% e especificidade de 88.5% com ponto de corte de 0.0-4.4. Conclusões: A medida enzimática da ß-glucosidase ácida em sangue seco é um excelente teste para o diagnóstico inicial de doença de Gaucher. No entanto, não é uma prova conclusiva. [Vera-Cala LM, Serrano-Gómez SE, Córtes A, Estrada I, Gáfaro A. Validade do teste de atividade enzimática da glucocerebrosidase para o diagnóstico da doença de Gaucher, revisão sistemática. MedUNAB 2017; 20(2): 201-206].

Mutações da glicocerebrosidade em pacientes com doença de Parkinson / Glucocerebrosidase mutations in Parkinson's disease patients

Introdução: A doença de Parkinson é uma enfermidade neurodegenerativa decorrente da perda de neurônios dopaminérgicos na substância negra, principalmente, e em outras regiões cerebrais. Caracteriza-se clinicamente por tremor, rigidez, bradicinesia e instabilidade postural. O tratamento é sintomático e consiste essencialmente na reposição da dopamina deficiente. A etiologia da doença de Parkinson ainda não é conhecida, mas os recentes avanços da Neurologia trouxeram novos conhecimentos acerca dos mecanismos fisiopatológicos envolvidos. Disfunção mitocondrial, estresse oxidativo e degradação de proteínas são alguns dos processos celulares que foram relacionados à degeneração dos neurônios dopaminérgicos. O campo da genética da doença de Parkinson tem recebido atenção especial na última década, graças à descoberta de vários genes associados ao desenvolvimento da doença. Um fator de risco genético recentemente descrito é a presença de mutações no gene da glicocerebrosidase, uma enzima lisossomal cuja deficiência resulta na doença de Gaucher. Apesar de a maioria dos estudos já publicados terem confirmado esta associação, um trabalho mais recente da Noruega não encontrou significância estatística ao analisar a presença destas mutações em pacientes com doença de Parkinson, tornando o assunto ainda controverso. Objetivo: Pesquisar a presença de mutações da glicocerebrosidase em pacientes com diagnóstico de doença de Parkinson no Brasil, acompanhados no ambulatório de Distúrbios do Movimento do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo e correlacionar tais achados com estudos recém-publicados que analisaram esta associação em outras populações em âmbito mundial, além de descrever possíveis características dos pacientes portadores de mutações que os diferenciem de não portadores. Métodos: Foram incluídos no estudo 65 pacientes com o diagnóstico de doença de Parkinson e idade de início da doença inferior ou igual a 55 anos e 267...

Introduction: Parkinson's disease is a neurodegenerative disorder due to the loss of dopaminergic neurons in the substantia nigra, primarily, and in other brain regions. It is clinically characterized by tremor, rigidity, bradykinesia and postural instability. Treatment is symptomatic and consists essentially in replacing the deficient dopamine. The etiology of Parkinson's disease remains unknown, but recent advances in Neurology have provided data concerning the pathophysiological mechanisms involved. Mithocondrial dysfunction, oxidative stress and protein degradation are some of the cellular processes that have been linked to dopaminergic neurons degeneration. The field of genetics in Parkinson's disease has gained special attention in the past decade, thanks to the discovery of several genes associated with the development of the disease. A recently described genetic risk factor for Parkinson's disease is the presence of glucocerebrosidase gene mutations. Glucocerebrosidase is a lysosomal enzyme which is deficient in Gaucher disease. Although most studies published to date have confirmed such association, a recent article from Norway could not find statistical significance when Parkinson's disease patients were analyzed for glucocerebrosidase mutations, generating controversy. Objective: To search for glucocerebrosidase mutations in Parkinson's disease patients in Brazil, followed at the Movement Disorders Division at Hospital das Clínicas, University of São Paulo Medical School, and correlate these findings with recently published studies which evaluated this association in other populations worldwide, besides describing possible features of patients carrying the mutations that may help differentiating them from non-carriers. Methods: Sixty five patients diagnosed with Parkinson’s disease, with disease onset before age 55, and 267 age and sex-matched controls were included in the study. DNA analysis of the three most common glucocerebrosidase...

Downregulation of neurotrophic factors in the brain of a mouse model of Gaucher disease: implications for neuronal loss in Gaucher disease

Gaucher disease is a glycosphingolipid storage disease caused by deficiency of glucocerebrosidase, resulting in the accumulation of glucosylceramide in lysosomes. The neuronopathic forms of this disease are associated with neuronal loss and neurodegeneration. However, the pathophysiological mechanisms leading to prenatal and neonatal death remain uncharacterized. To investigate brain dysfunction in Gaucher disease, we studied the effects of neurotrophic factors during development in a mouse model of Gaucher disease. The expression of brain-derived neurotrophic factor and nerve growth factor was reduced in the cerebral cortex, brainstem, and cerebellum of Gaucher mice, compared with that in wild-type mice. Extracellular signal-regulated kinase (ERK) 1/2 expression was downregulated in neurons from Gaucher mice and correlated with a decreased number of neurons. These results suggest that a reduction in neurotrophic factors could be involved in neuronal loss in Gaucher disease.

Upregulation of Proinflammatory Cytokines in the Fetal Brain of the Gaucher Mouse

Gaucher disease is caused by a deficiency of glucocerebrosidase. Patients with Gaucher disease are divided into three major phenotypes: chronic nonneuronopathic, acute neuronopathic, and chronic neuronopathic, based on symptoms of the nervous system, the severity of symptoms, and the age of disease onset. The characteristics of patients with acute neuronopathic- and chronic neuronopathic-type Gaucher disease include oculomotor abnormalities, bulbar signs, limb rigidity, seizures and occasional choreoathetoid movements, and neuronal loss. However, the mechanisms leading to the neurodegeneration of this disorder remain unknown. To investigate brain dysfunction in Gaucher disease, we studied the possible role of inflammation in neurodegeneration during development of Gaucher disease in a mouse model. Elevated levels of the proinflammatory cytokines, IL-1alpha, IL-1beta, IL-6, and TNF-alpha, were detected in the fetal brains of Gaucher mice. Moreover, the levels of secreted nitric oxide and reactive oxygen species in the brains of Gaucher mice were higher than in wild-type mice. Thus, accumulated glucocerebroside or glucosylsphingosine, caused by glucocerebrosidase deficiency, may mediate brain inflammation in the Gaucher mouse via the elevation of proinflammatory cytokines, nitric oxide, and reactive oxygen species.